Association of Compliance With Process-Related Quality Metrics and Improved Survival in Oral Cavity Squamous Cell Carcinoma

Abstract

IMPORTANCE Quality metrics for patients with head and neck cancer are available, but it is unknown whether compliance with these metrics is associated with improved patient survival. OBJECTIVE To identify whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at a tertiary academic medical center among 192 patients with previously untreated oral cavity squamous cell carcinoma who underwent definitive surgery with or without adjuvant therapy between January 1, 2003, and December 31, 2010. Data analysis was performed from January 26 to August 7, 2015. INTERVENTIONS Surgery with or without adjuvant therapy. MAIN OUTCOMES AND MEASURES Compliance with a collection of process-related quality metrics possessing face validity that covered pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. Association between compliance with these quality metrics and overall survival, disease-specific survival, and disease-free survival was calculated using univariable and multivariable Cox proportional hazards analysis. RESULTS Among 192 patients, compliance with the individual quality metrics ranged from 19.7% to 93.6% (median, 82.8%). No pretreatment or surveillance metrics were associated with improved survival. Compliance with the following treatment-related quality metrics was associated with improved survival: elective neck dissection with lymph node yield of 18 or more, no unplanned surgery within 14 days of the index surgery, no unplanned 30-day readmissions, and referral for adjuvant radiotherapy for pathologic stage III or IV disease. Increased compliance with a “clinical care signature” composed of these 4 metrics was associated with improved overall survival, disease-specific survival, and disease-free survival on univariable analysis (log-rank test; P < .05 for each). On multivariable analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity, increased compliance with these 4 metrics was associated with improved overall survival (100% vs ≤50% compliance: adjusted hazard ratio [aHR], 4.2; 95% CI, 2.1-8.5; 100% vs 51%-99% compliance: aHR, 1.7; 95% CI, 1.0-3.1), improved disease-specific survival (100% vs ≤50% compliance: aHR, 3.9; 95% CI, 1.7-9.0; 100% vs 51%-99%: aHR, 1.3; 95% CI, 0.6-2.9), and improved disease-free survival (100% vs ≤50% compliance: aHR, 3.0; 95% CI, 1.5-5.8; 100% vs 51%-99% compliance: aHR, 1.6; 95% CI, 0.9-2.7). CONCLUSIONS AND RELEVANCE Compliance with a core set of process-related quality metrics was associated with improved survival for patients with surgically managed oral cavity squamous cell carcinoma. Multi-institutional validation of these metrics is warranted.

Evaluation of Quality Metrics for Surgically Treated Laryngeal Squamous Cell Carcinoma

“…In other studies, 13,21 multidisciplinary tumor board evaluation for patients with locally advanced head and neck cancer was associated with favorable oncologic outcomes, 21 and congruence between multidisciplinary treatment planning conference recommendations and actual treatment provided conferred a survival benefit in a heterogeneous cohort of patients with head and neck cancer. 13 A prior study 12 that evaluated quality metrics for surgically treated oral cavity SCC found no association between multidisciplinary evaluation and survival. Oral cavity SCC is managed almost exclusively with up-front surgery, suggesting that multidisciplinary evaluation may be more beneficial for planning optimal therapy in the setting of 2 or more alternative treatment options, particularly when decision making is complex and multifactorial.…”

“…16 Additional potential quality metrics with face validity were developed in a multidisciplinary fashion at our institution as previously described. 12 …”

Effect of time to initiation of postoperative radiation therapy on survival in surgically managed head and neck cancer

“…Despite the NCCN’s endorsement of the preferred time to initiation of PORT for patients with HNSCC, the evidence underlying the recommendation is conflicted with regards to its effect on locoregional recurrence and survival 13 , with some finding benefit 14–21 and others finding no influence 10,11,22–26 . Many of these studies have been limited by retrospective single institution study design and small patient numbers 13 .…”

“…Prior studies have shown inconsistent effects on locoregional recurrence and survival, with some finding benefit 14–21 and others no influence 10,11,22–26 . Most of the studies finding benefit to earlier initiation of adjuvant therapy were conducted over 15 years ago.…”

Adherence to National Comprehensive Cancer Network guidelines for time to initiation of postoperative radiation therapy for patients with head and neck cancer

“…Discrepancies between guideline-directed care and delivered care have been described across the spectrum of pretreatment evaluation, treatment, and posttreatment surveillance for patients with oral cavity cancer 13 and laryngeal cancer 14,15 and in the receipt of adjuvant therapy for patients who have head and neck cancer with high-risk features. Discrepancies between guideline-directed care and delivered care have been described across the spectrum of pretreatment evaluation, treatment, and posttreatment surveillance for patients with oral cavity cancer 13 and laryngeal cancer 14,15 and in the receipt of adjuvant therapy for patients who have head and neck cancer with high-risk features.…”